Le centre de jour interne d’un service de gérontologie

In this article is reported the experience of a Gerontology department in the treatment of psychological and behavioral disorders, by means of an internal day care center. Historically, the creation of a day care center, within the Gerontology departement of the Bicêtre hospital (France), was the result of a reflection and experiences carried out for several years, about the difficult care of inpatients with psychological and behavioral disorders. The project was designed to meet the need of creating a place where these disorders might be more completely understood and treated. Given the previous experiences in this department and in others, the day care center had to reach several aims:

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to be comforting and to allow affective relations, pleasure and meaning;

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to protect and give the desire of being;

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to enable analysis and care of behavioral disorders;

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to keep or better the cognitive state;

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to strengthen the autonomy;

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to propose individual care;

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to reduce the use of psychotropic medications.

The main indications of the day care center are the psychological and behavioral disorders in dementia; these disorders are bound directly to dementia or are symptoms of anxiety, depression or delusion. Limits are imposed by the patient condition, particularly if there is a very severe cognitive impairment, an apathy or certain personality disorders. In the day care center, several therapeutic approaches may be gathered:

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psychotherapy techniques individually or in a group;

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re-education or re-learning of cognitive functions that is rather a play activity than a school class;

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social activities : meetings, meals, outside visits;

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body care : massage, relaxation, esthetics;

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work therapy, artistic activities : music, cooking…

Whatever kind of therapy is used, the affective dimension is the most important. A study of the effectiveness of the day care center had been carried out during the first year of activity (2000-2001). Twenty one patients had been included and they had stayed in the center for six months on average; 11 with Alzheimer dementia, 2 vascular dementia, 2 fronto-temporal dementia, 3 with old psychiatric pathologies and 3 somatic pathologies. The patients state had been assessed by several scales: Mini Mental State Examination, Cohen-Mansfield Agitation Inventory, Cornell Scale for Depression, Activities of Daily Living, Instrumental Activities of Daily Living. The findings of the study were that the condition of certain patients was clearly bettered by the stay in the day care center; these patients had a mild or average cognitive impairment (MMS > 10) or were depressed (Cornell > 10). But the assessment of severe dementia is very difficult, and some psychological improvements in the condition of these patients can't be taken into account by scales. Thus, this day center can take care of many patients including those with severe cognitive impairment and associated disorders; in addition, it must play a role of observation, analysis and research in order to optimize care in the whole department.     

Comparaison des expériences dissociatives à l'adolescence entre un groupe de collégiens et un groupe clinique

Dissociation involves alterations in consciousness, memory and identity, as well as disruptions in the perception of time and the environment. They contain an inability to remember aspects of one’s life, the experience of feeling oneself in an unfamiliar situation, feelings of unreality, feeling absorbed or completely lost in an activity, and feeling of being detached or disconnected from oneself. These experiences are conceptualized as existing on a continuum ranging from non-clinical conditions to pathological dissociation. Dissociatives experiences are relatively common in the general population, occur equally often in American male and female subjects, and tend to be reported less frequently with age. Data of these experiences are unknown in French adolescent subjects. In 1994, the DSM-IV deleted the notion of hysteria and neurosis and keeps only the notion of dissociative disorders. They included now the five following categories: dissociative amnesia, dissociative fugue, depersonalization disorder, dissociative identity disorder, dissociative disorder not otherwise specified (including derealization). The purpose of this study will compare the frequency of dissociative disorders between a sample of normal adolescent population and a clinical sample of adolescents. Further, results will be compared to the theoric structure of DES’s components to understand differences of dissociative experiences between the two populations. Clinical sample (N = 55) is made up of French adolescents aged 12-17 (mean age = 14.6; 36.4% is female population). Subjects were streaming from several pedopsychiatric unities. Normal sample (N = 96) is made up French adolescents aged 13-17 (mean age = 15.1; 51% is female population). Subjects were streaming from a secondary school. The screening tool, which was used is the dissociative experiences scale, a 28-item patient questionnaire regarding various dissociative symptoms. The subject is asked to indicate the percentage of time, to the nearest 5%, that particular symptom is experienced. The score is made by adding the various percentages and finding a mean that is expressed in numbers from 0 to 100. The mean score obtained is 26.15% for secondary school pupils sample and 19.24% for clinical sample. Comparison of the theoric three-factor solution (imaginative absorption, depersonalization-derealization, and dissociative amnesia) gives the following datas: mean score for each factor is, respectively: imaginative absorption = 32.72% for secondary school pupils group, 19.46% for clinical group; dissociative amnesia = 23.97% for secondary school pupils group, 18.31% for clinical group; depersonalization-derealization = 20.45% for secondary school pupils group, 19.65% for clinical group. DES reliability was studied through computation of Cronbach’s coefficient (0.84 for secondary school pupils and 0.92 for clinical sample). Results are paradoxical: reliability is good for the two samples and results are highest for non-clinical population, particularly for imaginative absorption component. An interpretation of this phenomena is, from the point of view of psychopathology and psychodynamics processes at adolescence, that the adolescent who is afflicted and feels psychic pain, is in difficulty to be in a good introspective capacity and to answer thinly to this sort of scale. Suffering adolescents tend to reduce score at DES, facing their own anxiety to be mad or abnormal. The authors mention so that an adolescent in a psychic good health is more able to develop an internal psychic world and can be involved to frequent moments of imaginative absorption, especially for female population (results show a significative difference).     

Les troubles de la marche dans la maladie de Parkinson : problématique clinique et physiopathologique

Gait disorders and axial symptoms are the main therapeutic challenges in advanced Parkinson's disease (PD). Gait disorders in PD are characterized by spatial and temporal dysfunction. Gait hypokinesia is the first to appear and is responsible for the decrease in velocity. A good sensitivity to the levodopa is well established. Morris et al. [Morris ME, Iansek R, Matyas TA, Summers JJ. Ability to modulate walking cadence remains intact in Parkinson's disease. J Neurol Neurosurg Psychiatry 1994a;57(12):1532-4; Morris ME, Iansek R, Matyas TA, Summers JJ. The pathogenesis of gait hypokinesia in Parkinson's disease. Brain 1994b;117(Pt. 5):1169-81; Morris ME, Iansek R, Matyas TA, Summers JJ. Stride length regulation in Parkinson's disease. Brain 1996;119:551-68] demonstrated that the ability to modulate walking cadence remains intact in PD, and could correspond to a compensatory mechanism. More advanced disease stages of the disease are characterized by abnormal temporal parameters (such as stride length variability, stride time variability and cadence elevation) which are unresponsive to levodopa therapy and may be correlated with the occurrence of falls and freezing of gait (FOG). Lastly, postural instability also results in falls and is poorly responsive to levodopa. A link between gait impairment and frontal disorders has recently been suggested. After a few years of evolution, paradoxical episodic phenomena are described: festination (“hastening gait” with rapid small, short steps) and FOG (involuntary and sudden cessation of gait). Both symptoms are often incapacitating for PD patients, because of their resultant loss of independence and their poor response to levodopa therapy. Kinematical studies of FOG revealed a decrease in velocity, stride length and an exponential increase in cadence, prior to a FOG episode. New approaches (functional MRI, wavelets…) should offer new perspectives concerning these disabling symptoms.     

L’hypnose ericksonienne et sa pratique dans le trauma psychique

Hypnosis is both a natural phenomenon that everyone experiences everyday, a communication technique or a therapeutic procedure when used as such with specific aims and tasks. In this article, we will discuss the use of Ericksonian hypnosis and opportunities for management of psychological trauma.     

Manifestations psychopathologiques dans la maladie de Gilles de la Tourette

Psychopathological and psychiatric comorbidities occur in approximatively 90% of patients suffering from Gilles de la Tourette's syndrome. Attention-deficit/hyperactivity disorders and obsessive-compulsive disorders are the most common syndromes. Troubles in controlling impulses and self-mutilation behaviors also constitute major handicaps that may lead to the social isolation of patients.     

Prise en charge psychothérapeutique de la douleur dans la fibromyalgie. À propos d’un cas

Fibromyalgia has an historic link with the neurasthenia from the end of the 19th century. It has been recently identified as a syndrom after other names have been used such as fibrositis, polyalgic syndrom and chronic fatigue syndrom. The new criteria of the American College of Rheumatology are now including psychological symptoms as fatigue, lack of sleep, cognitive disorders. It shows that this pathology oscillates between the somatic and the psychological poles in its definition. The physiopatholgy of fibromyalgia remains uncertain and the main medical model of understanding this condition is based on the bio-psycho-social model of stress. The therapeutic strategies used for managing fibromyalgia include analgesics, antidepressants educational therapy and relaxation. We will present a case report with a therapeutic approach based on psychosomatic and psychotherapy using psychoanalytical concepts. Concepts such as retention, anger repression, splitting are used with the view of explicitating the link between physical and psychological symptoms. We can approach fibromyalgia as a tensional pathology in a broad sense. The therapeutical relationship is also explored and how it is possible to help the patient to mentalize, to deal with anxiety and painful grief which are deeply repressed. The physical pain is becoming chronic because the ego can find a way to satisfy different drives by overinvestment of the pain. The process of identification to the father is also explicated. We will see that we have to be quite flexible with the therapeutic setting, and also that the act of prescribing can be useful to the psychotherapist.     

Les thérapies par l’hypnose dans les armées,quelques jalons dans l’histoire

About 1790, the three Puységur brothers, officers in the French Army, treated soldiers by magnetism or artificial somnambulism. Later, about 1880, Bernheim and Charcot explored under hypnosis soldiers shocked by combat. In 1885, when applying hypnosis to the soldier Louis V., the two navy psychiatrists Bourru and Burot were the first to discover the pathogenic part of the traumatic memories buried in the unconscious. Later, during the two mondial wars, hypnosis was used for the treatment of war neuroses. In present time, hypnosis and para-hypnotic relaxation are sometimes used for treating war traumas.     

Validation d’un questionnaire interactif sur la santé mentale des enfants de 6 à 11 ans

The “Dominic Interactive” is a computerized pictorial questionnaire used for the assessment of 6 to 11 years-old children’s mental health. The pictures illustrate the abstract emotional and behavioural content of most frequent mental health problems based on DSM-IV symptomatology. The cederom-based “Dominic Interactive” was given to 253 community children from voluntary Aix-en-Provence schools and to 150 children from 4 child psychiatric clinics. In the child psychiatric clinics referred children also received clinical diagnoses. Prevalence estimates and symptom scores yielded by the “Dominic Interactive” in referred children were significantly higher than those in general population. Since the “Dominic Interactive” is like a playful practical game of very easy use, its acceptability by both children and professionals was excellent.     

Comparaison statistique entre des cas de rupture et des cas de traitement dans un service de psychiatrie d'enfants

Résumé Parmi les 796 enfants venus consulter un service de psychiatrie ambulatoire et présentant les diagnostics de troubles réactionnels, troubles du développement ou troubles névrotiques, on a isolé 67 enfants dont les parents avaient accepté le traitement proposé et 52 dont les parents l'avaient refusé. Des comparaisons établies entre ces 2 lots montrent que les enfants et les familles de chacun de ces 2 groupes présentent des caractéristiques particulières. Notamment les garÇons, les enfants issus de classes moyennes et favorisées, les Suisses, les ainés et les intermédiaires, les filles de famille nombreuse, font plus souvent l'objet d'un traitement.

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Summary Sixty-seven children whose parents accepted treatment and 52 whose parents refused it were selected from among 796 children consulting an outpatient psychiatric service and who were diagnosed as reactive disorders, developmental difficulties or neurotic illnesses. Comparisons between the two groups indicated that the children and families of each group possessed certain specific characteristics: those accepting treatment tended to be boys, children of middle or upper class families, of Swiss nationality, oldest children and those of intermediate birth order and the daughters of large families.

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Cette étude a été réalisée avec l'aide du Dr. N. Sartorius, responsable du Bureau de la Santé Mentale à l'O. M. S. Nous lui sommes très reconnaissants de ses conseils et suggestions.     

L'apport d'une classification internationale des troubles mentaux dans la compréhension de la psychopathologie de Wolfgang Amadeus Mozart (1756-1791)

The ICD-10 (International classification of diseases, 10th revision), in its chapter dealing with mental disorders, has been constructed in a way that allows it to be used in various cultural settings. This classification can also provide a tool for diagnosing people who lived before the conceptualization of modern psychiatric nosology. Mozart (1756-1791) is perhaps one of the most famous composers, due to the genius of his music but also as a result of his controversial "temperament". Beyond the reputation that arises from these sources, the exact personality and psychiatric disorder(s) from which Mozart may have suffered are still not sufficiently understood. The study of Mozart's letters and his biography leads us to consider the psychiatric disorders from which he may have suffered. We detail some elements of his biography in connection with plausible psychopathological episodes, thus drawing new conclusions about the disorders from which he suffered. Mozart was born in Salzburg in 1756 to a musician father and a mother who had already given birth to six other infants, only one of whom was still living at the time, a four-year-old sister. He became a talented composer but was described as unpretentious, kind, cheerful and extraverted. During his adolescence, there is no indication of the presence of any mental disorder. But later, in accordance with previous literature, it seems that he demonstrated depressive episodes, some of which were severe and correspond to the criteria of the international classification ICD-10. In June 1788 for example, Mozart wrote: "… if such black thoughts did not come to me so often, thoughts which I banish by a tremendous effort, things would be even better." This remark constitutes a relatively specific element in favor of a depressive episode, even if no other clues appear in his letters from this period. In 1790, Mozart's words then explicitly indicate that he suffered from a severe depressive episode: he mentioned a depressed mood, a markedly diminished interest in his activities (e.g. in composing), a diminished ability to concentrate, loss of energy and feelings of excessive guilt. Thus, Mozart described five criteria for the diagnosis of a major depressive episode. "If people could see into my heart, I should almost feel ashamed - to me everything is cold - cold as ice." However, others have claimed the occurrence of some depressive episodes (for instance after the death of his mother) that are excluded by this nosological conception. Also, the arguments put forward by other authors supporting the occurrence of manic or hypomanic episodes (thus constituting a bipolar disorder diagnosis) are not supported by sufficient historic proof. He wrote letters which were incoherent in some parts; but hypomanic episodes can be excluded, as letters written the days before and after these above-mentioned ones are clearly and adequately conceived. This excludes the likelihood of a hypomanic state of duration of more than four days, as required by ICD-10 criteria. Thus, there are no diagnostic criteria for a bipolar II disorder (i.e. the presence of depressive and hypomanic episodes). The diagnosis of a cyclothymic disorder is more difficult to exclude: the length of hypomanic periods is not specified in classifications, but the symptoms must cause clinically significant distress or impairment in social functioning. Mozart suffered social and interpersonal difficulties (i.e. lack of security, affective loneliness), which are at least partially related to some of his behaviors and/or mood instability. This could be due to the presence of a personality disorder. Mozart featured personality traits which correspond to the criteria for dependent personality: difficulties acting on his own (for instance with regard to his relationship with his father); need to be nurtured and supported by others (i.e. his wife); feeling uneasy or helpless when alone. Traits of the borderline personality disorder can also be drawn from his correspondence: efforts to avoid real or imagined abandonment; impulsiveness (also described in some of his biographies); affective instability due to a marked reactivity of mood (which may account for some clinical situations having been described as depressive episodes); and a feeling of emptiness. The current conceptualization of psychiatric disorders allows us to conclude that Mozart suffered from depressive episodes in the background of a personality disorder characterized by dependent as well as borderline traits. Nevertheless, this conclusion may be challenged by authors who consider that the mood lability and brief hypomanic-like episodes that Mozart featured represent core characteristics of the so-called "soft bipolar spectrum" rather than a personality disorder feature. Indeed, there is a growing trend to lower the time criterion for hypomania and even to include hyperthymic traits (which are indisputably present in Mozart) as a constitutive element of a bipolar II disorder in the presence of depressive episodes. Thus, the psychiatric history of Mozart exemplifies nosological uncertainties that are still a source of debate in today's psychiatric research.     

Coping et qualité de vie dans la sclérose en plaques et la maladie de Parkinson : une réflexion clinique

Objective

In neurological disorders, such as multiple sclerosis (MS) and Parkinson’ s disease (PD), psychological and adaptive processes have not been extensively investigated, it has, however, been demonstrated that they have a great impact on “quality of life” (QoL). Interestingly, even though these two diseases affect people of different ages, both of them have a substantial impact on mood and QoL. In these two diseases, the authors objective was to analyse the style of coping in relation with the QoL taking depression and anxiety into account.

Methods

Two hundred and seventy MS and PD subjects were seen for a semistructured interview in order to collect sociodemographic and clinical information, after which there was an assessment of their mental and cognitive states using: the Mini International Neuropsychiatric Interview (MINI), the Montgomery and Asberg Depression Rating Scale (MADRS), the Depressive Mood Scale (EHD), the Hamilton Anxiety scale (HAMA) and the Frontal Assessment Battery (FAB). Then, all subjects completed three self-report questionnaires; two about coping strategies: the Ways of Coping Checklist (WCC), the Coping with Health, Injuries and Problems scale (CHIP), and one about QoL: the SEP 59 for MS and the French version of PDQ-39 for PD.

Results

The studies show that the psychosocial dimension of QoL is preserved in the two diseases studied. They also demonstrated that in MS and PD the two factors associated with a poor QoL are depression and emotion-focused coping strategies. Furthermore, these variables are highly dependent on the clinical courses in MS and motor signs in PD. However, the MS patients tended to be more irritable and to lose the control of their emotions more easily than PD patients.

Discussion

The report discusses the importance, first, of identifying these manifestations in patients with MS or PD and, second, of offering patients interventions tailored to the characteristics of each disorder. The authors propose some examples of psychotherapy, which could be used with neurological patients. The studies show that it is also important to work with MS and PD patients on both the expression and the management of their emotions in connection with their diseases.     

Traitements pharmacologiques des troubles psychocomportementaux dans la maladie d’Alzheimer

Behavioural symptoms are common in Alzheimer's disease and may affect up to 90% of patients. Different drug therapies may be indicated and these symptoms need correct evaluation before prescribing. Management is complex and based on therapeutic strategy such as nonpharmacologic and pharmacologic treatment. The first step should always be nonpharmacologic but some drugs such as cholinergic therapy and psychotropic have shown efficacy on these symptoms. When prescribed, they need careful evaluation of risk/benefit.